The Smart Medical Practice

Pop Heath: What It Really Means Right Now for Physicians


Population health management
Population health management includes providing an array of services to a diverse population.

Population health management has to be more than a trendy catchphrase if it’s going to make a difference in patient care. Physicians and others have their own definitions for population health management, but most agree that it involves the actions of a single practice or clinically integrated network to provide an array of patient services. These range from screenings and clinical treatments to smoking cessation, nutrition counseling, and staff interventions. In short, population health management can involve everything necessary to keep a patient population healthy and reduce the need for more intensive, costly care down the line.

Payers are telling physicians to look beyond their practices and shift their focus from caring for individual patients to caring for whole populations as part of value-based care initiatives. This approach requires better communication with patients and caregivers and, often, additional staff and technology to manage patients with chronic disease.

That could be a tall order for a small practice with only a few physicians and limited staff.

As the push to implement population health initiatives gains steam, many practitioners aren’t thinking about how best to manage their patient populations. Instead, they’re pondering whether their private practices can survive the changes necessary to participate in this emerging model of care. Small to midsized offices implementing population health initiatives may need to redesign their practice model to accommodate the incentive payment models that require practitioners to closely monitor patients.

Fortunately, it is possible to build a population health management program incrementally, and you might be further into the process than you think.

From the beginning: EHR and Practice Management software

Your first step is figure out where your practice stands. Your office has probably implemented some of the components of population health management already. For example, your EHR system is gathering patient information that meets certain population health reporting requirements as outlined by Meaningful Use and its descendent, MACRA.

As far back as 2010, Agency for Healthcare Research and Quality (AHRQ) interviews with providers showed that practices with EHRs equipped with patient registries were performing some practice-based population health management functions.

Modern EHR and medical practice management systems do more by enabling providers to focus on their patients’ preventive care needs, including individuals who seldom appear in the office for routine checkups. This can help practices conduct more comprehensive health promotion and disease management.

Once you know what capabilities you have in hand, the second step is choosing on what to focus. Practice management software can serve a variety of population health goals. For example, modern systems can generate lists of patients to invite to educational sessions about basic fitness, diabetes, chronic disease self-management, smoking cessation, and other programs outside the practice. More advanced systems can identify patients who may be eligible for clinical trials or additional care options under Medicare and other government programs.

Critical IT functions

Population management depends on robust information management. Back in 2010, the AHRQ identified key health IT functions that support proactive population management that are even more crucial today. They include:

  • Identifying subpopulations of patients, allowing practices to find their patients who require preventive care or tests.
  • Honing common characteristics of subpopulations, so practices can run queries to more accurately determine care options, access patient records, or seek additional patient information.
  • Alerting capabilities that remind patients and providers, making patient information “actionable” through notifications for patients and members of the practice.
  • Performance metrics that allow practices to gauge how their care compares to national guidelines or peer comparison groups.
  • Data that’s available in multiple formats, so the practice can print, save, export, import, or display it as necessary for multiple purposes. The same information may need to be rendered in different formats depending on whether it’s being provided for private insurance reimbursement, for CMS or accreditor reporting, or for the office accountant.

It’s critical to understand that your practice can’t do it all, even if it seems as though certain private insurers and CMS haven’t grasped this point. All sides agree that population health management will be most challenging for small practices, but some will thrive. Those with charismatic, passionate physicians who foster patient engagement, committed managers, and adequate financial and technological resources have the best chances of success.

Population health management
Practices with charismatic, passionate staff will likely succeed at population health management.

Others may be forced to collaborate or align with clinically integrated networks, with or without outright ownership by the network. Such partnerships allow a small practice to gather data, report on performance measures, and better support cohorts of at-risk patients rather than waiting for them to suffer an acute event that requires episodic care.

Effective population health management will require additional, affordable technological innovations that enable more usable, available data. Patient attitudes toward their health must also change. In our get-it-done-yesterday world, the hardest part of population health management may be the time it will take to get things right.


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